Amanda Cleeve
Karolinska Institutet, Women and Child health, Department Member
- Midwife and PhD-studentedit
Background: Contraceptive adherence is the current and consistent use of a contraceptive method as prescribed by a health worker or family planning provider so as to prevent pregnancy. Globally, adherence is lowest among adolescents. This... more
Background: Contraceptive adherence is the current and consistent use of a contraceptive method as prescribed by a health worker or family planning provider so as to prevent pregnancy. Globally, adherence is lowest among adolescents. This has greatly contributed to the high burden of adolescent pregnancies. Adherence and reasons for discontinuation among refugee adolescents are poorly understood. The aim of this study was to determine the rates and predictors of adherence to modern contraceptives among female refugee adolescents in northern Uganda.Methods: A prospective single cohort study, nested into a randomised controlled trial (RCT) assessing the effect of peer counselling on acceptance of modern contraceptives. The RCT was conducted among female refugee adolescents in Palabek refugee settlement, northern Uganda. The study involved 272 new starters of modern contraceptives who were followed up for six months from May 2019 to January 2020. The outcome was measured at one, three ...
SPIRIT checklist (DOC 122 kb)
UNCST approval. Approval letter from the Uganda National Council of Science and Technology which provides oversight on research done in Uganda. (PDF 190 kb)
Research proposal IRB approval. Approval letter from Makerere University School of Medicine Research and Ethics Committee. (PDF 934 kb)
Barriers to access abortion services globally have led to the development of alternative methods to assist and support women who seek an abortion. One such method is the use of hotlines, currently utilised globally for abortion care. This... more
Barriers to access abortion services globally have led to the development of alternative methods to assist and support women who seek an abortion. One such method is the use of hotlines, currently utilised globally for abortion care. This review aimed to understand (1) how abortion hotlines facilitate access to abortion; and (2) how women and stakeholders describe the impact of hotlines on abortion access. Published quantitative and qualitative studies and grey literature were systematically reviewed alongside an identification and description of abortion hotlines in the public domain. Our findings highlight that the existence of abortion hotlines is highly context-dependent. They may exist either as an independent community-based model of care, or as part of formal care pathways within the health system. Hotlines operating in contexts with legal restrictions seem to be broader in scope and will use innovative approaches to adapt to their setting and reach hard-to-reach populations....
Research Interests:
As part of its core work, the WHO generates, translates and disseminates knowledge, including through guideline development. In recent years, substantial work has been undertaken to revise the Evidence to Decision framework in order to... more
As part of its core work, the WHO generates, translates and disseminates knowledge, including through guideline development. In recent years, substantial work has been undertaken to revise the Evidence to Decision framework in order to fully integrate inter alia human rights. This paper describes an innovative methodological approach taken by the authors to inform law and policy recommendations for the forthcoming third edition of the Safe Abortion: Technical and Policy Guidance for Health Systems. The methodology described here effectively integrates human rights protection and enjoyment as part of health outcomes and analysis, ensuring that subsequent recommendations are consistent with international human rights standards. This will allow guideline users to make informed decisions on interventions, including legal and policy reform, to fulfil relevant human rights including the right to health.
Research Interests:
Background The unmet need for contraceptives among refugee adolescents is high globally, leaving girls vulnerable to unintended pregnancies. Lack of knowledge and fear of side effects are the most reported reasons for non-use of... more
Background The unmet need for contraceptives among refugee adolescents is high globally, leaving girls vulnerable to unintended pregnancies. Lack of knowledge and fear of side effects are the most reported reasons for non-use of contraceptives amongst refugee adolescents. Peer counselling, the use of trained adolescents to offer contraceptive counselling to fellow peers, has showed effectiveness in increasing use of contraceptives in non-refugee adolescent resarch. Objective To determine the effect of peer counselling on acceptance of modern contraceptives among female refugee adolescents in northern Uganda. Methods A randomised controlled trial carried out in Palabek refugee settlement in northern Uganda, May to July 2019. Adolescents were included if they were sexually active or in any form of union, wanted to delay child bearing, and were not using any contraceptives. A total of 588 consenting adolescents were randomised to either peer counselling or routine counselling, the stan...
Research Interests:
We performed a country case study using thematic analysis of interviews and existing grey and published literature to identify facilitators and barriers to the implementation of midwife‐provided abortion care in Sweden. Identified... more
We performed a country case study using thematic analysis of interviews and existing grey and published literature to identify facilitators and barriers to the implementation of midwife‐provided abortion care in Sweden. Identified facilitating factors were: (1) the historical role and high status of Swedish midwives; (2) Swedish research and development of medical abortion that enabled an enlarged clinical role for midwives; (3) collaborations between individual clinicians and researchers within the professional associations, and the autonomy of clinical units to implement changes in clinical practice; (4) a historic precedent of changes in abortion policy occurring without prior official or legal sanction; (5) a context of liberal abortion laws, secularity, gender equality, public support for abortion, trust in public institutions; and (6) an increasing global interest in task‐shifting to increase access and reduce costs. Identified barriers/risks were: (1) the lack of systems for monitoring and evaluation; and (2) a loss of physician competence in abortion care.
Research Interests:
Research Interests:
Research Interests:
We performed a search in PubMed and Web of Science on the self-use of abortion medication after online access. Studies published between January 1, 1995, and March 31, 2019, were considered. We included studies of online services that... more
We performed a search in PubMed and Web of Science on the self-use of abortion medication after online access. Studies published between January 1, 1995, and March 31, 2019, were considered. We included studies of online services that were (i) led by healthcare staff (n = 14), (ii) led by non-healthcare staff (n = 4), and (iii) providing noninteractive access (n = 17). Our outcomes were utilization (frequency and demand for services), acceptability for women, safety, and success rate. Key findings: Women are increasingly using the Internet to access abortion medication. Available services are of varying quality. Women accessing noninteractive services report feelings of distress related to the lack of medical guidance, and the demand for interactive guidance through the abortion process is high. Women using services led by healthcare staff report high rates of satisfaction and similar rates of clinical outcomes as those of in-person abortion care.
Research Interests:
OBJECTIVE We aimed to explore midwives' perspectives on post-abortion care (PAC) in Uganda. Specifically, we sought to improve understanding of the quality of care. DESIGN This was a qualitative study using individual in-depth... more
OBJECTIVE We aimed to explore midwives' perspectives on post-abortion care (PAC) in Uganda. Specifically, we sought to improve understanding of the quality of care. DESIGN This was a qualitative study using individual in-depth interviews and an inductive thematic analysis. SETTING AND PARTICIPANTS Interviews were conducted with 22 midwives (the 'informants') providing PAC in a public hospital in Kampala, Uganda. The narratives were based on experiences in current and previous workplaces, in rural and urban settings. FINDINGS The findings comprise one main theme - morality versus duty to provide quality post-abortion care - and three sub-themes. Our findings confirm that the midwives were committed to saving women's lives but had conflicting personal morality in relation to abortion and sense of professional duty, which seemed to influence their quality of care. Midwives were proud to provide PAC, which was described as a natural part of midwifery. However, structural challenges, such as lack of supplies and equipment and high patient loads, hampered provision of good quality care and left informants feeling frustrated. Although abortion was often implied to be immoral, the experience of PAC provision appeared to shape views on legality, leading to an ambiguous, yet more liberal, stance. Abortion stigma was reported to exist within communities and the health workforce, extending to both providers and care-seeking women. Informants had witnessed mistreatment of women seeking care due to abortion complications, through deliberate care delays and denial of pain medication. KEY CONCLUSION AND IMPLICATIONS FOR PRACTICE Midwives in PAC were dedicated to saving women's lives; however, conflicting morality and duty and poor working conditions impeded quality of care. Enabling midwives to provide good quality care includes increasing the patient-midwife ratio and ensuring essential resources are available. Additionally, efforts that de-stigmatise abortion and promote accountability are needed. Implementation of policies on respectful post-abortion care could aid in ensuring all women are treated with respect.
Research Interests:
Research Interests:
Background Misoprostol is established for the treatment of incomplete abortion but has not been systematically assessed when provided by midwives at district level in a low-resource setting. We investigated the eff ectiveness and safety... more
Background Misoprostol is established for the treatment of incomplete abortion but has not been systematically
assessed when provided by midwives at district level in a low-resource setting. We investigated the eff ectiveness and
safety of midwives diagnosing and treating incomplete abortion with misoprostol, compared with physicians.
Methods We did a multicentre randomised controlled equivalence trial at district level at six facilities in Uganda.
Eligibility criteria were women with signs of incomplete abortion. We randomly allocated women with fi rst-trimester
incomplete abortion to clinical assessment and treatment with misoprostol either by a physician or a midwife. The
randomisation (1:1) was done in blocks of 12 and was stratified for study site. Primary outcome was complete
abortion not needing surgical intervention within 14–28 days after initial treatment. The study was not masked.
Analysis of the primary outcome was done on the per-protocol population with a generalised linear-mixed eff ects
model. The predefi ned equivalence range was –4% to 4%. The trial was registered at ClinicalTrials.gov, number
NCT01844024.
Findings From April 30, 2013, to July 21, 2014, 1108 women were assessed for eligibility. 1010 women were randomly
assigned to each group (506 to midwife group and 504 to physician group). 955 women (472 in the midwife group
and 483 in the physician group) were included in the per-protocol analysis. 452 (95·8%) of women in the midwife
group had complete abortion and 467 (96·7%) in the physician group. The model-based risk difference for midwife
versus physician group was –0·8% (95% CI –2·9 to 1·4), falling within the predefi ned equivalence range (–4% to
4%). The overall proportion of women with incomplete abortion was 3·8% (36/955), similarly distributed between
the two groups (4·2% [20/472] in the midwife group, 3·3% [16/483] in the physician group). No serious adverse
events were recorded.
Interpretation Diagnosis and treatment of incomplete abortion with misoprostol by midwives is equally safe and
effective as when provided by physicians, in a low-resource setting. Scaling up midwives’ involvement in treatment of
incomplete abortion with misoprostol at district level would increase access to safe post-abortion care.
Funding The Swedish Research Council, Karolinska Institutet, and Dalarna University.
assessed when provided by midwives at district level in a low-resource setting. We investigated the eff ectiveness and
safety of midwives diagnosing and treating incomplete abortion with misoprostol, compared with physicians.
Methods We did a multicentre randomised controlled equivalence trial at district level at six facilities in Uganda.
Eligibility criteria were women with signs of incomplete abortion. We randomly allocated women with fi rst-trimester
incomplete abortion to clinical assessment and treatment with misoprostol either by a physician or a midwife. The
randomisation (1:1) was done in blocks of 12 and was stratified for study site. Primary outcome was complete
abortion not needing surgical intervention within 14–28 days after initial treatment. The study was not masked.
Analysis of the primary outcome was done on the per-protocol population with a generalised linear-mixed eff ects
model. The predefi ned equivalence range was –4% to 4%. The trial was registered at ClinicalTrials.gov, number
NCT01844024.
Findings From April 30, 2013, to July 21, 2014, 1108 women were assessed for eligibility. 1010 women were randomly
assigned to each group (506 to midwife group and 504 to physician group). 955 women (472 in the midwife group
and 483 in the physician group) were included in the per-protocol analysis. 452 (95·8%) of women in the midwife
group had complete abortion and 467 (96·7%) in the physician group. The model-based risk difference for midwife
versus physician group was –0·8% (95% CI –2·9 to 1·4), falling within the predefi ned equivalence range (–4% to
4%). The overall proportion of women with incomplete abortion was 3·8% (36/955), similarly distributed between
the two groups (4·2% [20/472] in the midwife group, 3·3% [16/483] in the physician group). No serious adverse
events were recorded.
Interpretation Diagnosis and treatment of incomplete abortion with misoprostol by midwives is equally safe and
effective as when provided by physicians, in a low-resource setting. Scaling up midwives’ involvement in treatment of
incomplete abortion with misoprostol at district level would increase access to safe post-abortion care.
Funding The Swedish Research Council, Karolinska Institutet, and Dalarna University.